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• �� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR. PUMP PERMIT- Permit No. ZL/L <br /> i! THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued / <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local. Health District for a permit to construct <br /> and/or. install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION , r rye, 1 .lam-`-�y../,[I�7 " CENSUS TRACT <br /> /� I- Zed <br /> Owner's Name Phone <br /> Address /00 120 " D /;d l 0 City � <br /> ` Phone f 4icense d �' l • <br /> Contractor's Name � 'vG� L --- <br /> TYPE OF WORK (Check): NEW WELL/LT-DEEPEN /7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMEgf_; 2 I "" T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ti Industrial Ca le. Tool Dia. of Well Excavation / <br /> t,­-Domestic/private Drilled Dia. of Well Casing <br /> r <br />? : Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal S"- <br /> i Cathodic Protection Rotary Type of Grout fid) <br /> i <br /> Disposal Other Other Information 11 <br /> k <br /> Geophysical Surf ace Seal installed B <br /> E PUMP INSTALLATION: Contractor <br /> Type of Pump A.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP_!REPAIR: m /_7 State Work Done <br /> ES•'£RUCTION OF WELL: Well Diameter Approximate Depth <br /> ` Describe Material and Procedure <br /> r !i <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District e <br /> WELL DRILLERS REPORT of the well and notify them before putting the- well in use.. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> k PRIOR TO GR UTI G AND',A.5pl INSPECTION. <br /> SIGNED TITLE .i� - <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r DATE / �S <br /> APPLICATION ACCEPTED BY C ' <br /> ADDITIONAL COMMENTS: ." <br /> PHASE It GROUT INSPECTION PRASE III/ TAL INSPECTION <br /> INSPECTION BY DATE J z73 `'�� INSPECTION BY C • ',_..__-DATE 7r <br /> R u 1/A9A Pov_ 1-74 1-74 2M-=- _ <br />